Client Intake Form

First name

Last name

What brings you to this service?

What are the main skin concerns you are looking to target?

(acne, pigmentation, sensitivity, anti-aging, relaxation, etc.)

Do you have any allergies, or has your skin ever had any reaction to a cosmetic product?

(food, ingredients, medicine, anything)

Do you have any medical conditions I should be aware of?

(diabetes, thyroid disorders, autoimmune conditions, heart conditions, epilepsy etc.)

Are you currently taking any medications, vitamins or supplements?

Are you taking Accutane (roacutan) or using any topical retinoids such as tretinoin (retin-a), adapalene, or retinol?

(please specify frequency of use and how long you have been using it)

When was the last time you had a facial, botox, laser, peel or any dermocosmetic procedure?

please be specific (date and treatment)

Are you pregnant or breastfeeding?

Describe your current AM skincare routine? Please be as detailed as possible.

(brand, name, etc.)

Describe your current PM skincare routine Please be as detailed as possible.

(brand, name, etc.)

Have you had any sun exposure recently or plan on spending time in the sun in the next few days?

Any upcoming events I should be aware of?

(wedding, trip, celebration etc.)

I give my consent for the facial treatment and acknowledge I have shared all relevant health information.

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